Asthma Patient Counseling: Join the Pharmacist Revolution

Patient counseling is part of therevolution of the pharmacist.As pharmacists'responsibilityhas evolved from dispenser to a disseminatorof information, patient counselinghas become a cornerstone forpharmaceutical care. Research hasproven that medication adherenceranges from 20% to 70% for chronicconditions, such as asthma.¹ Pharmacist-provided education can improveadherence rates and patient understanding.^2-4 The National Asthma Educationand Prevention Program recognizesthe need for pharmaceutical careand recommends that asthma educationbe integrated throughout asthmacare.⁵ Even though patient education isperceived as important by pharmacists⁶and other health care professionals,⁵ in a 1990s study researchersreported that between 40% and 67%of patients do not talk with their pharmacistabout their medications.⁷ Eventhough pharmacists are specificallytrained to provide medication education,patients may lack an understandingabout the expanded counselingfunction that pharmacists possess.⁷Because patients lack awareness of thisskill, it is up to pharmacists to open thedoor of communication when providingcounseling about asthmatic treatments.

Important Points to Cover

Most patients do not have a completelycorrect inhaler technique,which may lead to less than optimaldelivery and suboptimal efficacy of themedication. The majority of retail pharmacistswho provide patient counselingare very busy and are being pulledin several different directions; quick andconcise counseling techniques are necessary.

DIPS [Dosage, Instructions,Priming, Special Instructions] is aneasy-to-remember acronym that coversmost of the important parts regardingcorrect use of inhalers.

DIPS

D. Is the patient going to be using 1or 2 inhalations? Will the dosage bescheduled or as needed? This is also aneasy transition to discuss the indicationof the medication—rescue, longtermcontrol, or combination product.If a bronchodilator and maintenancemedications are prescribed, the patientneeds to use the bronchodilatorfirst, wait 5 minutes, and then use themaintenance inhaler.

I. The instructions can vary accordingto which delivery system is beingused. Metered dose inhalers (MDIs)require coordination, which can be difficultfor small children and the elderly.The patient needs to breathe out andpress down on the canister whilebreathing in. Patientsshould hold this breath forup to 10 seconds, or aslong as they are comfortable.The patient needs toshake the inhaler and waitapproximately 1 minutebetween inhalations, ifmultiple inhalations areprescribed.⁸ Most companiescan provide placeboversions of their inhalersupon request. The use of aplacebo inhaler can be veryhelpful when demonstratingcorrect inhaler technique. Thepatient should subsequently be able todemonstrate the technique, as mostpeople do not have questions or do notdiscover problems until the first use ofa product.

Dry powder inhalers may be morepatient-friendly and do not require thepatient to coordinate breathing andproduct delivery. The patient does needto keep the inhaler parallel to theground after the dose has beenreleased to keep the powder in thedelivery channel before inhalation. Besure to warn the patient that humidity,including patient breath, can cause thepowder to clump together. Patientexhalation into the device prior toinhalation can also cause that dose toexit the device.

P. MDIs require priming (ie, 2 to 4sprays in the air) before use if theproduct is new or unused for a certain amount of time (Table). If thepatient does not prime the device,less than the desired dose of activeingredient may be received. Educatepatients that this is an important partof inhaler use, especially if they usetheir rescue albuterol inhaler infrequently.Dry inhalers require no suchpriming.

S. Inhalers are like no other deliverydevice and have special instructionsfor each type of device. Some relativelynew inhaler devices require specialinstructions (eg, some are breath-actuated,and some require capsulesto be inserted into the device). Forinhalers that require capsules, patientsneed to be aware that the capsule isnot to be ingested and needs to bereplaced with each use. For MDIs, thecorrect amount of medication in eachcanister is measured in a certainamount of actuations. After that specificnumber of actuations, eventhough the canister does not feel completelyempty, the canister should bediscarded. Placing an inhaler in waterto see if it floats does not indicate ifthe canister is empty—this is nolonger considered appropriate or accurate.Patients need to rinse and spitfollowing the inhalation of corticosteroids,because MDIs may also leadto oropharyngeal deposition, whichcan cause hoarseness and thrush.Cleaning of inhalers is not necessary;wiping with a moist, clean rag issufficient.

Areas of Patient Confusion

"My asthma medication isn't working"is a common statement pharmacistsshould expect to hear. This statementshould lead pharmacists to checkpatient inhaler technique and useopen-ended questions to discover theproblem.⁹

Language Barrier

Patients and health care providershave different definitions for commonlyused medical terminology.¹⁰ A patientmay define controller or longtermcontroller as a medication thatcontrols symptoms, and he or she willuse this medication when symptomsoccur that need to be controlled.Rescue medication can have differentmeanings to the patient and provider.The phrase "rescue medications openthe airways" is often used to describethe mechanism of action of the rescuemedication. The patient may misunderstandthat the force of the productexiting the inhaler inflates the lungs.

Expectations

Patients'expectations also affecthow they view the efficacy of theirmedication. Patients may expect to feelor taste the medication when they inhale,and if correct technique is usedthis should not occur. Patients mayanticipate feeling systemic side effects,such as heart palpitations or excitation.

To correct or prevent incorrect inhalertechnique, ask patients to describeunder what circumstances theyuse each medication, provide verbaland written education, and demonstrateproper techniques.

Dr. Knudsen is a clinical pharmacistat Arizona Medical Clinic in Peoria,Ariz.

References

1. Boulet LP. Perception of the role and potential side effects of inhaledcorticosteroids among asthmatic patients. Chest. 1998;113:587-592.

2. De Tullio PL, Corson M. Effect of pharmacist counseling on ambulatory patients'use of aerosolized bronchodilators. Am J Hosp Pharm. 1987;44:1802-1805.

3. Self TH, Brooks JB, Lieberman P, Ryan MR. The value of demonstration and roleof the pharmacist in teaching the correct use of pressurized bronchodilators. CanMed Assoc J. 1983;128:129-131.

4. Stiegler KA, Yunker NS, Crouch MA. Effect of pharmacist counseling inpatients hospitalized with acute exacerbation of asthma. Am J Health Syst Pharm.2003;60:473-476.

5. National Asthma Education and Prevention Program. Expert panel report:guidelines for the diagnosis and management of asthma: update on selectedtopics—2002. J Allergy Clin Immunol. 2002;110(suppl 5):141-219. Available at:www.nhlbi.nih.gov/guidelines/asthma/asthmafullrpt.pdf.

6. Schommer JC, Wiederholt JB. Pharmacists' perceptions of patients' needs forcounseling. Am J Health Syst Pharm. 1994;51:478-485.

7. Schommer JC. Patients' expectations and knowledge of patient counselingservices that are available from pharmacists. Am J Pharm Educ. Winter1997:61;403-406.

8. Proventil HFA [package insert]. Kenilworth, NJ: Key Pharmaceuticals Inc; 1996,1999. Available at: www.spfiles.com/piproventilhfa.pdf. Accessed February 5,2007.

9. Lewis RK, Lasack NL, Lambert BL, Connor SE. Patient counseling—a focus onmaintenance therapy. Am J Health Syst Pharm. 1997;54:2084-2098.

10. Rubin BK. What does it mean when a patient says, "My asthma medication is notworking?" Chest. 2004;126:972-981.